Some Notes on the Institute of Medicine's Panel
on "Complementary and Alternative Medicine"
Stephen Barrett, MD
In 2003, The Institute of Medicine (IOM) assembled a committee to identify major scientific and policy issues in "complementary and alternative medicine" ("CAM") research, regulation, training, credentialing and "integration with conventional medicine." The committee was expected to "develop conceptual frameworks to guide decision-making on these issues and questions." However, it would not conduct new surveys of "CAM" use by the American public or "assess the efficacy or safety of CAM products." The project was sponsored by the National Institutes of Health and the Agency for Healthcare Research and Quality. According to an NIH news release, the committee would be composed of "leading scholars drawn from both conventional medicine and CAM, and from education," and "should serve to complement the recommendations of the White House Commission on Complementary and Alternative Medicine Policy."
In February 2003, the IOM Web site posted the names of 15 appointees and asked for public comment about their suitability. Unfortunately, the proposed committee did not appear to contain a single knowledgeable critic. At least half of its members had a direct or indirect economic interest in the project's outcome, and several had actively promoted quack methods. Among those who were qualified to make scientific judgments, I suspected that few if any understood how deceptively "CAM" methods are marketed. In March, in response to public comments—including mine—two of the less qualified original members (Sherman Cohn, JD, LLB, LLM and Leanna J. Standish, ND, PhD, Dipl Ac) were dropped. Later, Joyce Anastasi, RN, PhD, FAAN, LAc; Michele Chang, MPH, CMT; David Nerenz, PhD; and Harold Sox, MD, were added.
The following table summarizes my assessment of the finalists and links to detailed information about each one.
"CAM" Committee Member
Beliefs or Practices
of CAM's Value
|Stuart Bondurant, MD (Chair)*||Yes||None apparent||None apparent|
|Joyce K. Anastasi, PhD, RN, FAAN, LAc*||Yes||Yes||Yes|
|Brian Berman, MD*||Yes||Yes||Yes|
|Margaret Buhrmaster||Unclear||None apparent||None apparent|
|Gerard Burrow, MD||None apparent||None apparent||None apparent|
|Michele Chang, MPH, CMT||Yes||Unclear||Unclear|
|Larry Churchill, PhD||None apparent||None apparent||None apparent|
|Florence Comite, MD||Yes||Yes||Yes|
|Jeanne Drisko, MD||Yes||Yes||Yes|
|David M. Eisenberg, MD*||
|Alfred P. Fishman, MD*||Yes||None apparent||Yes|
|Susan Folkman, PhD*||Yes||Yes||Yes|
|Albert Mulley, MD||None apparent||None apparent||None apparent|
|David Nerenz, PhD||
|Mark Nichter, PhD, MPH||None apparent||None apparent||None apparent|
|Bernard Rosof, MD, FACP||None apparent||None apparent||None apparent|
|Harold Sox, MD||
|9 or 10||6 or 7||8 or 9|
"Complementary and alternative medicine" ("CAM") is an imprecise marketing term that is inherently misleading. "Alternative" methods are loosely described as practices outside of mainstream health care. They lack evidence of safety and effectiveness and are generally not covered by insurance plans. "Complementary medicine" is loosely described as a synthesis of standard and alternative methods that uses the best of both. In truth, there are no "alternatives" to objective evidence of effectiveness and safety. As noted by former editors of the top two American medical journals:
There is no alternative medicine. There is only scientifically proven, evidence-based medicine supported by solid data or unproven medicine, for which scientific evidence is lacking. Whether a therapeutic practice is 'Eastern' or 'Western,' is unconventional or mainstream, or involves mind-body techniques or molecular genetics is largely irrelevant except for historical purposes and cultural interest. . . . As believers in science and evidence, we must focus on fundamental issues—namely, the patient, the target disease or condition, the proposed or practiced treatment, and the need for convincing data on safety and therapeutic efficacy. [Arnold Relman, M.D. A trip to Stonesville. The New Republic, Dec 14, 1998.]
* * * * *
There cannot be two kinds of medicine —conventional and alternative. There is only medicine that has been adequately tested and medicine that has not, medicine that works and medicine that may or may not work. Once a treatment has been tested rigorously, it no longer matters whether it was considered alternative at the outset. If it is found to be reasonably safe and effective, it will be accepted. But assertions, speculation, and testimonials do not substitute for evidence." [Philip B. Fontanarosa M.D., George D. Lundberg, M.D., . Alternative medicine meets science. JAMA 280:1618-1619, 1998]
* * * * *
What most sets alternative medicine apart . . . is that it has not been scientifically tested and its advocates largely deny the need for such testing. By testing, we mean the marshaling of rigorous evidence of safety and efficacy, as required by the Food and Drug Administration (FDA) for the approval of drugs and by the best peer-reviewed medical journals for the publication of research reports. Of course, many treatments used in conventional medicine have not been rigorously tested, either, but the scientific community generally acknowledges that this is a failing that needs to be remedied. Many advocates of alternative medicine, in contrast, believe the scientific method is simply not applicable to their remedies. . . .
Alternative medicine also distinguishes itself by an ideology that largely ignores biologic mechanisms, often disparage modern science, and relies on what are purported to be ancient practices and natural remedies (which are seen as somehow being simultaneously more potent and less toxic than conventional medicine). Accordingly, herbs or mixtures of herbs are considered superior to the active compounds isolated in the laboratory. And healing methods such as homeopathy and therapeutic touch are fervently promoted despite not only the lack of good clinical evidence of effectiveness, but the presence of a rationale that violates fundamental scientific laws—surely a circumstance that requires more, rather than less, evidence.[Jerome Kassirer, M.D., Marsha Angell, M.D., Alternative Medicine—The risks of untested and unregulated remedies. New England Journal of Medicine 339:839-841, 1998]
Put another way, the prevailing scientific view is that "CAM" methods that are plausible should be tested with well-designed clinical trials. The rest should be discarded. No method should be marketed, promulgated, or taught without proof that it is safe and effective. I am amazed that IOM thinks it can issue advice about "CAM" methods without considering their plausibility.
The WHCCAMP Fiasco
In 2000, Bill Clinton appointed a White House Commission on Complementary and Alternative Medicine Policy "to provide a report to the President on "legislative and administrative recommendations for assuring that public policy maximizes the benefits to Americans of complementary and alternative medicine." However, almost every member of the Commission had an economic interest in the report and the majority were unscientific practitioners.
The commission's report, completed in March 2002, recommended across-the-board "integration" of "CAM" into government health agencies and the nation's medical, medical education, research, and insurance systems -- a situation that would promote unscientific practices and waste countless millions of taxpayer dollars. Throughout the report, the Commission implied that "CAM" is a well-defined medical discipline rather than a marketing term used to promote unproven methods. It failed to acknowledge that science-based medicine is already a highly "integrative" process and that all it requires of any therapy is objective scientific evidence that it works. (There are no "alternatives" to objective evidence of effectiveness and safety.) The Commission falsely assumed that "CAM" research is cost-effective and that "CAM" methods have been sufficiently developed to integrate into every aspect of our educational and health-care delivery systems. Its report does not identify a single "CAM" practice that should be considered improper. Moreover, the Commission did not even propose criteria for evaluating "CAM" practices for safety or effectiveness—a major flaw in their work.
The report was carefully contrived to suggest that "CAM" is close to the mainstream and that its critics are on the fringe, when, in fact, just the opposite is true. Two of the 19 Commissioners warned HHS Secretary Thompson—correctly—that the report was biased and that the process of preparing it was corrupt. Quackwatch and the National Council Against Health Fraud posted a paragraph-by-paragraph analysis of the WHCCAMP report that tore it to smithereens. Bush Administration officials, the major news media, and the medical press quickly grasped the situation and did not welcome the report's findings.
Despite the poor quality of the report, former WHCCAMP chairman James E. Gordon, M.D., was one of three people invited to give lengthy testimony at the first public meeting of the IOM "CAM" committee on February 27, 2003. Subsequent to the meeting, I learned that "CAM" committee chairman Stuart Bondurant, M.D., had been appointed Special Assistant to the President of Georgetown University, which, in 2001, was awarded a five-year, $1.7 million NIH grant to "develop and implement a comprehensive, innovative program that incorporates complementary and alternative medicine into the School of Medicine curriculum." Gordon is co-director of the program. This means that Bondurant has a major conflict-of-interest when it comes to making policy recommendations regarding "CAM" education.
A Stacked Deck
In letters and phone calls to the project administrator, I said that if the Institute of Medicine wanted to do better than the White House Commission, it should replace several of "CAM" Committee members with science-based individuals who understand what "CAM" really means and who have no economic interest in the outcome of the IOM "CAM" report. When the final composition of the committee was announced, it was obvious that the report would be untrustworthy. My prediction came true. Except for a recommendation that the Dietary Supplement and Health Education Act be modified to protect consumers, the report was very similar to the WHCCAMP report.
This page was revised on January 15, 2005.